A nurse is assessing a client who has peripheral artery disease for potential safety concerns. Which of the following client statements should the nurse report to the provider?

"l need to walk slowly as I lose my balance often."

"l don't go out much because of the pain in my legs."

"It makes me sad that I can't keep up with my grandchildren."

"l have a small-healed area on my spine that is painful."

Answer and Explanation

The Correct Answer is A

A. "I need to walk slowly as I lose my balance often": This statement indicates a potential safety concern related to balance issues while walking. Loss of balance can increase the risk of falls, especially in individuals with peripheral artery disease (PAD) who may already have compromised circulation and reduced sensation in their legs. The nurse should report this statement to the provider for further evaluation and intervention to prevent falls and promote safety.

B. "I don't go out much because of the pain in my legs" : While this statement suggests that the client experiences pain in their legs, it does not directly indicate a safety concern that requires immediate reporting to the provider. Pain management strategies may be discussed with the provider to address this issue.

C. "It makes me sad that I can't keep up with my grandchildren" : While this statement reflects emotional distress related to the client's inability to participate fully in activities with their grandchildren, it does not indicate a specific safety concern that requires reporting to the provider. However, addressing the client's emotional well-being is important for overall holistic care.

D. "I have a small-healed area on my spine that is painful" : This statement describes a painful area on the client's spine but does not directly relate to potential safety concerns associated with PAD. The nurse may further assess this issue and include it in the client's overall assessment, but it does not require immediate reporting to the provider for safety concerns related to PAD.

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Correct Answer is C

Explanation

A. Marfan's syndrome: Marfan's syndrome is a genetic disorder that affects the connective tissue in the body, predisposing individuals to various cardiovascular, skeletal, and ocular abnormalities. While Marfan's syndrome can present with certain cranial and intracranial manifestations, such as dural ectasia and intracranial aneurysms, it is not typically considered a direct risk factor for traumatic brain injury (TBI).

B. Hypercarbia: Hypercarbia refers to elevated levels of carbon dioxide (CO2) in the blood. While severe hypercarbia can lead to cerebral vasodilation and potentially exacerbate intracranial pressure in individuals with traumatic brain injury, it is not considered a direct risk factor for TBI itself.

C. Falls: Falls are a significant risk factor for traumatic brain injury (TBI), particularly in older adults and young children. Falls can occur due to various factors such as environmental hazards, impaired mobility, balance issues, or neurological conditions. Falls are a leading cause of TBI-related emergency department visits, hospitalizations, and fatalities.

D. Ventriculostomy: Ventriculostomy involves the placement of a catheter into the ventricular system of the brain to monitor intracranial pressure (ICP) or drain cerebrospinal fluid (CSF). While ventriculostomy is a procedure commonly performed in the management of severe traumatic brain injury to monitor and manage intracranial pressure, it is not a risk factor for TBI itself.

A. "l notice the ringing when I'm not concentrating on something." B. "l am still able to complete my work in a timely manner." C. "The ringing in my ears is distracting." D. "Hopefully a treatment for this ringing in my ears will help."

Correct Answer is C

Explanation

A. "I notice the ringing when I'm not concentrating on something." This statement suggests that the client notices the tinnitus but does not imply a significant impact on their well-being. It indicates that the tinnitus occurs when the client is not focused on tasks, which may not necessarily affect their overall functioning or well-being.

B. "I am still able to complete my work in a timely manner." This statement indicates that the client can still function adequately in their work despite experiencing tinnitus. While this may suggest some level of coping, it does not directly address the impact of tinnitus on the client's overall well-being.

C. "The ringing in my ears is distracting." This is the correct answer. This statement indicates that the tinnitus is distracting to the client, which suggests that it may affect their concentration, focus, or overall quality of life. The distraction caused by tinnitus can significantly impact daily activities and well-being.

D. "Hopefully a treatment for this ringing in my ears will help." While this statement acknowledges the presence of tinnitus and the desire for treatment, it does not directly address the impact of tinnitus on the client's well-being. It focuses more on the hope for relief through treatment rather than the current impact on their quality of life.

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A nurse is assessing a client who has peripheral artery disease for potential safety concerns. Which of the following client statements should the nurse report to the provider?

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